Tuesday, December 24, 2013

Thursday, November 07, 2013

It was shaping up to be a pretty good day. I got up a little early, packed my lunch, put the dog outside, left for work on time, and made it to work without incident.

Where I walked in to find a patient, destined to be my project for the day, sitting on the floor of his room, screaming. And kicking and tantruming. Like a three-year-old. Refusing to get off the floor. Floods of tears. Demands that we call varied and sundry people.

I've got such a hangover from that day that I still can't form complete sentences.

Here's all you need to know: functional exam, drug-seeking, requesting Dilaudid (of course). Fourteen chart notes by the end of the shift just on my part. Approximately twelve hundred words from the various therapies. Screaming. Crying. More screaming. More demands for Dilaudid. Refusal of blood tests, vital signs, drugs, and therapies.

Drama.

I have had bad days before. Never ever have I had a day that made me question why on earth I became a nurse. (Not that I'm seriously questioning it now, but at about 1700 on that fateful afternoon? Definitely.) If somebody had made a cartoon of my leaving work, there would've been little puffs of smoke coming off the ground under my sneakers.

At one point the patient told the docs that we had left him on the floor for an hour as he screamed for help. (Note here that he did not fall; he simply sat down and refused to move.) The attending shot me a look, to which I responded with my best BlankStupidFace.

I just. . . .I just. . . .don't get that shit. And I don't play into it, either. Late in the day, the patient refused to answer the simple, yes/no question of whether he'd like to go to the bathroom. I told him to use his words.

Yes. I snarked. But I have had it with crazy junkies who fake strokes. I've also had it with attending physicians who, faced with a clear MRI, a gorgeously normal CTA and CT, and perfectly fine bloodwork (all collected before my little prince had his meltdown) decide to order vasculitis panels, autoimmune panels, and umpteen other tests to determine if there's a physical reason for The Cray.

Boo, this patient is acting out and acting up. He is so far off the chain that the chain itself is lost behind the horizon. He won't accept treatment no matter what we do, so let him go. Let him go home, sans hydromorphone, and do his thing.

And for God's sake, don't bring him back. In a town this size, there are certainly some acceptable medical facilities that are not ours.

Wednesday, October 30, 2013

Three years ago at this time I was lying on the couch, watching St. Elmo's Fire with Friend Pens The Lotion Slut, feeling rather giddy from a combination of red wine and Vicodin. I had just had the majority of my hard palate and all of my soft palate removed due to a case of oral cancer. If you want to read the whole story, go back to September of 2010 in the archives.

(St. Elmo's Fire is a good movie filled with terrible people. Skip it; that way, you won't have to wish for that two hours of your Vicodin- and red-wine-soaked life back.)

Let's talk about oral cancers. There are a lot of them, some of them frightening, some of them less so. All of them are on, as they say, the rise, due to a number of factors. Here are some interesting things about OC that you may not know:

1. A large number of oral cancers are due to the human papilloma virus. In different forms, HPV can cause warts on your fingers, genital warts, cervical dysplasia and cancer, or lumps in your mouth, or oral cancer. There are innumerable strains of HPV. Most of them are harmless. Some are really a bitch to get and to treat.

2. Oral cancer, which used to be the province of men over the age of 60, is increasing in young women. Part of this has to do with the near-ubiquity of HPV in the population. A lot of it has to do with the fact that young women now smoke more and drink more than young men. Alcohol or smoking predisposes you to oral cancer; doing both at once is a great way to lose chunks of your tongue or jaw.

3. Oral cancer is underdiagnosed in young people. Part of this has to do with the fact that the thinking on OC hasn't caught up with the reality. Part of it has to do with how often young people visit the dentist. I go to the dentist twice a year; my OC was found by The Fantastic Hygienist at my dentist's office. It had grown from nothing to a two-centimeter lump that I had not noticed in half a year.

4. Oral cancer has a huge impact on your life, no matter how minor it is. I got lucky: all I have to do for the rest of my life is wear a metal-and-plastic prosthetic that protects my airway and allows me to speak, and get yearly checkups (complete with MRI and CT scans and all the associated radiation) to make sure that I still have no evidence of disease. Some people, like my pal Mary, have lost much, much more than that to this disease, and the consequences are ongoing.

5. Oral cancer can hit you even if you don't smoke, or drink, or have sex. Mary, for instance, had a stage III squamous cell carcinoma of the tongue that was HPV negative. She is a lifelong nonsmoker and nondrinker. OC doesn't play favorites.

6. Which leads me to THE MOST IMPORTANT POINT OF ALL: If you see or feel a weird bump in your mouth, get it checked out. If you've got a gut feeling about it, don't stop asking for answers until you know what's really going on. OC is still one of those things that docs don't expect to see in people my age (forties) without other risk factors. I was incredibly lucky in that I had a dentist who was paranoid as fuck about the thing on my palate. Other people have not been so fortunate; as a result, they've had to undergo things like feeding tube placements and the loss of all of their teeth.

My cancer, polymorphous adenocarcinoma, doesn't have known risk factors. The article in Wikipedia on it is still only a stub. It's rare, it's non-invasive (usually), and can normally be treated with what's called "wide excision," also known as "taking out most of your mouth and changing your life forever." The type of cancer I had was indolent, meaning that it didn't spread or grow very quickly. It could happen to anybody. It happened to me.

So, on this third, give or take, anniversary, I have this one request: think about oral cancer. Go to the fucking dentist. It doesn't matter if you haven't been in fifteen years; they get off on that stuff. Get your mouth checked out. Avoid what I went through.

Friday, October 25, 2013

This week was long. People, I tell you: wearing leads for seven hours a day, five days a week, will wear. you. the fuck. out.

Let me back up.

Sunday last I stepped through my bathroom floor. Yes, that bathroom floor. The bathroom floor that the Ex Chefboy and I spent something like six weeks demolishing and redoing. I stepped through the floor. Because it had rotted. From something. I don't know what. Don't ask me. La la la la laaaa.

Monday I started cross-training for angiography/interventional radiology/that weird place waaaaay down the hall in the basement next to the operating rooms where they make you wear hairnets, like, 24/7.

Tuesday I felt my hip joints grind in a way that I hadn't felt before.

Wednesday I was fairly confident with the charting, but still hating the leads. You try wearing ten or so poundses of lead on your top and bottom (ten pounds each, my friends) for several hours at a stretch and see how you like it.

Thursday I realized that they'd given me a male lead-vest with double shielding over the chest because nothing else would fit over my bazooms. And *that,* best-beloveds, is why aformentioned bazooms will be permanently droopy from here on out.

Today I discovered that, starting this coming week, I will be precepting a new nurse for twelve weeks. She's coming into the NCCU as a new hire. I have never, ever precepted a new person for that long. Not that I'll be doing it all by myself, but I'll be doing the majority of her Hey Lookit This Ain't This Cool edumacation.

And at some point during this week I realized that what I want, deep in my heart of hearts, more than happiness or a living wage or a fuzzy kitten, is a bidet.

Let me back up again.

It looks like at least one of the walls and most of the floor in the bathroom is/are a total loss. That means sledgehammering and chiseling and generally demolitioning the tile out and laying new Hardi-Board and waterproof stuff. Waterproof cement board is great, and it generally works, but it's not meant to withstand the bursting of a pipe that carries Unimaginable PSI of water under said waterproof board. I had, apparently, the one situation for which RedGard and Hardi-Board are not rated.

We don't have to do everything right now. Most of the demo and reconstruction can wait over the winter, thank Frogs. I can use that time to save up my pennies and decide what I really, really want in the bathroom. Which is kind of a story in itself. . .

Seven-nearly-eight years ago, subway tile was the exclusive province of Brooklyn hipsters. Seriously: they hadn't even moved out to Williamsburg yet, and subway tile was available only by special order through the big-box stores here. It's what I wanted, but couldn't afford, so I went with Pelican 1 x 1's all over the floor and up the walls and have kind of dealt with it ever since.

Now I'm looking at subway tile. And console corner sinks. And a BIDET.

I was introduced to the miracle that is the bidet in Denmark twenty-something years ago (also: that was the last time I rode a bike. Coincidence? Maaaybe.) and reintroduced to it while visiting Pal Joey in Quebec. Bidets, People, are the shizz. Nit. I swore that my Forever Home would include a bidet in every bathroom when I had a bathroom all to myself, complete with bidet, lo those many years ago.

But putting a bidet--a real one, not one of those toilet-seat make-do's, in the bathroom would require a smaller sink. Which I'm good with. I mean, what do you use a sink for? Washing your hands, taking off makeup, brushing your teefies. That's it. Corner sink = perfectly functional situation, if it means getting a bidet.

Say it with me: BEEEEEEEE-DAAAAAAAAAAAY.

Mmmmm. You see?

I have had fucking MOUTH CANSUH, and I will have my bidet now, thank you.

But back to the leads: I learned a whole, whole lot this week. Most of it was charting in a totally unfamilliar system, but some of it was fun stuff about how the hell G-tubes get put in, and what you have to worry about with patients who have aneurysms coiled, and how some doctors who are fine in the unit are assholes in the OR.

Most of what I learned can be boiled down to two things: If you have shoulder problems, like I do, get an apron instead of a vest. That way, the bulk of the weight can be carried around your waist rather than on your delicate bursal nerve plexus. Also, radiology techs are the coolest guys in the hospital. I worked with The Daves (two guys named Dave who are indistinguishable when in full sterile gear), and they were *so amazing.* The nurse who was training me was great, yes, but she didn't always catch all the stuff I was screwing up as I was doing it, and so couldn't correct me with a quiet word from under a mask. I brought The Daves cookies today. It was not enough.

Another thing I learned: if you really, really like your job and find interesting things in it every day, you will communicate that enthusiasm to the person you're helping out who's new. That's what The Daves and My New Pal Sherri (the nurse who trained me) and My Old Pal Andrea (the other nurse in the department) did. It was fun. And educational. And my shoulders hurt.

And one final thing I learned: If you give a woman a bidet once, she will not stop thinking about it for two decades.

3. Is this a problem that will require me to wake up Boyfiend for his opinion?

No. It can wait.

4. What are the best-case and worst-case scenarios when it comes to fixing this problem?

Best: Replace a few squares of floor tile

Worst: Rip out entire bathroom and replace everything; live with Boyfiend while bathroom is being dealt with

Median: Rip out part of the bathroom and replace, bathe in kitchen sink

5. What is likely to have caused this problem?

In descending order of likelihood:

a) Wonky plumbing in the wall that we didn't notice the first time
b) Rot from bad grout lines in the floor
c) Leftover damage from pipe breaking under house
d) Ants or termites or some other bug
e) Aliens have decided to use my bathroom floor as a portal to another universe

6. What does this mean for the problem as it stands?

Ask for Home Depot gift cards for Christmas. Wait until Boyfiend to drink coffee before examining the floor. Make popovers.

Saturday, October 05, 2013

A few folks have asked for updates on our Fantastic Integrated Computer System and about the woman who went to the non-accredited nursing school. Herewith:

The FICS is. . . .well, most of the functionality has been turned off. Which is nice, as it doesn't feel like Big Brother is right over your shoulder all the time. Basically, none of the tracking features worked right. Hell, the call lights and information boards in the rooms didn't even work right, so away they went, to be replaced with the old setups. Nobody is crying.

As for the tech who went to the wrong school: Somebody asked why accreditation makes a difference, if her grades were good and she'd had previous floor experience. It makes a difference because accreditation is the way that hospitals and clinics know that a particular school is teaching material that's up-to-date and useful. It's based, as far as I know, on things like NCLEX passing rates and the qualifications of the teaching staff as well as the course requirements. Whether or not it's one more bit of Press-Ganeyesque BS I don't know; all I know is that you simply won't get hired if you don't have a degree from a school with accreditation.

And yeah, she and I talked about it; she's going to work where she can until she gets enough experience that it won't matter where she went to school. I don't know if that'll work or not, but here's luck to her.

In other news, it's been a while since I gave y'all a good, old-fashioned, gross nursing story. Here you go:

The patient was a woman in her fifties or early sixties. She was obese, had alcohol and opiate dependency, and was diabetic. She was in the preop area of another hospital, prior to getting some toes snipped off, when she started complaining of a headache and then fell over and seized.

Big aneurysm. Big, big blown aneurysm. The hospital, having no flies on its collective self, transferred her to Sunnydale to have that aneurysm clipped, even though it wouldn't make much of a difference to her functionality. So she showed up at Sunnydale NCCU intubated and sedated, got her clipping done, and stayed intubated and sedated for about twenty-four hours (the usual routine).

Except that about six hours after surgery, both of her legs got all swollen and funky. Oops. That's not a part of the usual routine. Turns out she'd somehow clotted off her IVC filter. That's a doohickey that looks a little like a miniature colander--you get one in your inferior vena cava if you have large or repeated clots in your leg veins. It's supposed to strain out any clots that might go to your lungs or head and hurt you. Anyhow, hers got all full of clots, which basically means you lose the blood flow back to your heart from your lower body. If you're thinking that's not good, you'd be right.

Out comes the heparin drip. More clots, more problems. Eventually, she managed to sustain pretty substantial damage to both kidneys, which required pressor support (drugs that go through your IV line to help your body maintain a livable blood pressure) and continuous renal dialysis (which is a big blood-scrubbing machine that we only use when things are Indeed Dire). We cut off the heparin and started using leech spit (yes, really) to anti-coagulate her, but the damage was done. She had some clotting disorder that's rare enough in women (why do we always seem to find those?) that nobody had tested her for it until she came to us.

Here's where things get interesting. Patient had two sons, one of whom was beyond batshit on the crazy scale. Mama made one good decision in a rare moment of sobriety and made Sane Son her power of attorney and medical liason. He was all for stopping the heroic measures. Beyond Batshit Son, however, was still part of the family, and used his time in the NCCU to cause problems, raise hell, and generally put up such a fuss about continuing life support that the docs felt hogtied by family drama.

Meanwhile, the patient had infarcted her bowels, meaning she had a belly full of dead intestine. She'd put on about forty pounds of water weight and looked like an enormous balloon person in the bed. Her skin was weeping excess fluid all the time, to the point that we put super-absorbent pads all over the bed and hoped for the best. The only things keeping her alive at that point were nine different drips (I counted), a ventilator, a dialysis machine, and sheer dumb bad luck. Her hands and feet were gangrenous. She no longer responded even to pain. Her reflexes were gone.

Beyond Batshit Son, despite being told that her chances for recovery were nil, continued to insist that Mama be kept on life support. He even called Adult Protective Services to tell them that his brother was abusing Mama--imagine APS's surprise when they investigated and found a Mama-Lump in a bed in a critical-care unit. This continued for a couple of weeks, until I degloved one of Mama's legs by accident.

"Degloving" is a nice word for what happens when you're so sick, or so burned, or so generally unlucky that your skin simply comes off. We were turning her, using the pads we'd put under her to absorb fluid, when I felt something mushy in the pad under her thigh. I figured it was just the super-absorbent gel in the thing and shifted my grip. . .which was when the nurse across from me blanched and shuddered.

The skin on the back of Mama's left thigh had sloughed off her leg. You could see layers of fascia and muscle underneath, and the lump of shed skin and fat was hanging off in a flap. There wasn't any blood; even with multiple drugs to keep her blood pressure up, she wasn't pushing enough of the red stuff to bleed when that happened. She leaked clear fluid.

Shudder.

With that, the docs on the case sat down in a meeting, collectively sacked up, and turned off the ventilator. The patient, grateful for the relief, died without fuss four minutes later. Given that the accidental skinning happened over a weekend, it took 'em all a couple of days to get together, but they did it. Beyond Batshit Son was never on board with the decision and had to be escorted off the premises by a couple of no-nonsense cops.

And that, my friends, is your Requisite Gross Nursing Story for the month. Sweet dreams!

Monday, August 26, 2013

Dr. Ali and I were talking about our recent (constant) staffing problems last night. I said I couldn't figure out why a unit with patients with things like GBS and big MCA strokes (one makes you not breathe, the other can make you have fatal heart arrhythmias without warning) wasn't considered a priority in staffing. I mean, we had a code a couple of weeks ago when some poor sod went into ventricular fibrillation (non-medical definition: your heart quits beating and just shivers: very bad), and only one nurse on the floor. It was touch-and-go, but we got said poor sod coded, stabilized, and later discharged.

Dr. A. told me something he'd heard earlier this week from a VP of development: that the neurocritical care unit is only important in that we bring in money for the neurosurgical service.

(Imagine me standing there, open-mouthed, silent.)

Yeah.

Sunnydale General is supposedly going for a comprehensive stroke certification, but the department that handles everything from strokes requiring TPA to non-surgical neurological emergencies is considered worthwhile only because we send the occasional patient to the surgery guys for a cartotid endarterectomy or aneurysm clipping.

I asked Dr. Ali how he'd responded. He told me he'd told the VP of development that our unit was making plenty of money on its own, thanks, and that he didn't like to refer patients for surgeries that weren't proven to work. (That last is some obscure insult referencing some sort of study on CEAs, I guess; I don't know the details.) It was a calm, intellectual burn from one doc to another.

Still, to be told flat out that the unit that you're working on, that you've been helping to develop for umpteen years, isn't considered important by the big uppity-ups. . . .is disheartening. Although it does explain why we're having such a hard time getting funding for equipment and staff.

In other news, I worked with a patient care aide this weekend who was concerned about her ability to get a job after she graduates nursing school in December. She's been doing externships and internships and has great grades, but hasn't even had a nibble on the job front.

We went over all the things she was doing right, and all the things she might be doing wrong, and then I took a look at her resume.

She's graduating from a for-profit school that is not accredited.

Again, imagine me standing there, open-mouthed and silent.

This woman will owe more than $50,000 for two years' worth of classes from a school that lacks even the most basic accreditation from any authority. She therefore will not be able to get a job anywhere but the LTAC that employs her part-time now, and maybe not even them, as an RN. Add to that that her chances of getting into a decent nursing school for a BSN are practically nil, except if she goes back to Consolidated Larnin' Collidge, and she's screwed.

I can't. . .I can't even. Talk about predatory marketing: they promised her that in just under two years, she'd have earning potential that nobody in her family has ever had. They told her that the job market for nurses is hot, which it is--provided you've got a degree from a recognized school and are willing to slog for a few years. They then helped her get loans that are about four times what I paid for a degree from an accredited program, but didn't happen to mention that a) the interest rates are huge, and b) her education would be worth practically nothing.

She's not stupid, but she's not well-educated. She's poor, she's got a GED, and she took the only offer she got. She's a hard worker and driven as hell, but she's hobbled herself with a bullshit "degree" from a place that has classes in a storefront.

Thursday, August 01, 2013

I did not learn to make these when I was growing up. As far as I can remember, my Sainted Mother, being more or less a Yankee, never fried a green tomato, let alone okra or the leftovers of grits that had been left to become solid in the refrigerator.

At some point in the last ten years, though, I learned to make fried green tomatoes. They're not economical--very few people have enough tomato plants that finding a use for them is necessary, at the end of the season. They're not Paleo, or Atkins, or Clean--they're something you make as a special treat, to serve with fresh mozarella or shrimp or sausages, or just on their own, as soon as they come out of the pan.

They are purely Southern, in the sense that some version of FGTs extend from West Virginia all the way to Arizona. They are best made with green tomatoes found, by chance, at the farmer's market: the kind you get at the grocery store don't have enough flavor. Grab a half-dozen or so, stock up on cornmeal and breadcrumbs and fat, and go at it.

(This recipe can be made gluten free by the substitution of rice flour for the flour and gluten-free breadcrumbs for the breadcrumbs. Don't waste your money on panko; get the cheapest breadcrumbs you can find at the grocery store, or make your own from heels and odds of bread you've stored in your freezer. A blender helps here.)

You will need:

A large frying pan. Cast iron is best, but anything NOT non-stick will work.

A spatula or pancake turner.

Two large plates and a shallow bowl.

A fork. A knife. A horizontal surface onto which to slice the tomatoes.

Salt, breadcrumbs, cornmeal, pepper, at least three eggs, and a whole lot of oil or Crisco. Also four to six green tomatoes, the most symmetrical and greenest you can find.

To begin:

Obtain your tomatoes. Wash them briefly under cold running water and slice their ends off. Be miserly in slicing off the blossom end, as it's the most tender part, and promiscuous in slicing off the stem end. Green tomatoes have not yet formed a tough core, but who wants to eat stem? Now slice the tomatoes.

Some people swear by thick slices, at least a half-inch. I find I get better results with thinner slices--anything from a quarter-inch to almost paper-thin, depending on my mood and skill with the knife.

After slicing your fruit, lay them flat on a large plate or cutting board and salt them. You don't have to go nuts with the salt; this step is meant to draw out the extra juice and keep the breading from getting soggy. While they're sweating on the cutting board or plate, set up your breading station: on the first plate, dump a good amount of plain flour. On the second, dump equal amounts of breadcrumbs and corn meal, mixed well. I use a blender to do this because I am FANCY.

In the shallow bowl, mix up as many egg whites as you can scrounge up. Do not use whole eggs for this; the fat in the yolk will make your tomatoes soggy.

Now melt some Crisco (or lard) or heat up some vegetable oil (not olive!) (not butter!) (bacon grease is okay and traditional) in your frypan. You want it hot enough that a little pinch of flour sizzles when you toss it in there. Keep the heat at medium or medium-high. A half-inch of melted fat in the pan is the right amount. Too much and you'll end up with soggy, greasy tomatoes. Too little, and the fat will suck off all the cornmeal and burn.

Take your sliced tomatoes and pepper them. Press them gently into the flour. You want them coated with flour on each flat side. Don't worry about the edges where the skin is; they'll take care of themselves. (I do not recommend shaking the tomatoes with flour in a bag, as this will cause the innards of the tomatoes to fall out. Take the time to press them into the flour and you'll be much happier.)

Now dip them into the egg white. This will make your fingers gooey. Coat them with the breadcrumb-and-cornmeal mixture and set them aside in a single layer to wait for frying.

When the fat is hot, place five or so tomato slices into it. You want them to be uncrowded and in a single layer. Let them sit and sizzle until you see that they're beginning to get brown up the sides. Turn them carefully and allow to sizzle for a couple minutes more--the second side takes much, much less time than the first.

Remove to paper towels, (or do what the finest cook I know does: use slices of cheap white bread in place of paper towels. Use those bread slices to drain everything from bacon to fish, and then, at the end of a week or so, grill them by themselves and serve them with lots of ham gravy) and drain.

Continue in this way until the fat starts to smell like burning cornmeal. When that happens, stop everything. Take the pan off the heat and let it cool for a half-hour or so (your tomatoes will wait, I promise), then pour the fat out of the pan and replace it with clean fat. This step is essential. Otherwise, you'll end up with burnt-tasting FGTs.

You can eat them out of hand. You can layer them with slices of good mild cheese, or grate a tiny amount of good hard goat-cheese over them. You can cover them with shrimp or ham or sausage gravy. You can, if you like, layer them in a casserole with fresh sliced zucchini and ripe tomatoes and a little grilled eggplant and call it Southern Ratatouille, but I won't eat it.

They are best eaten as they are, with extra salt if you need it, off a plate, on a porch or in a kitchen in the middle of the dog days, below the Mason-Dixon line. You can fry okra or catfish if you have any cornmeal left over and feel very virtuous about not wasting food. I layer them with fresh mozzarella if I'm feeling fancy, or throw them into a roll with mayo, lettuce, and cheese and call it an FGT po-boy.

But most often I eat them as they come out of the pan, crisp and tangy and citrusy. These are the perfect bridge food between the humid hot horrible summer days of August and the crisper fall days to come. Enjoy.

Wednesday, July 17, 2013

Actually, he rolled in. On a stretcher. After a TIA. Transported by EMS from the airport. And it was, sadly, no joke.

There are surgeons nobody hears about, even if they've been working in the same place for twenty years. There are surgeons you only ever hear good things about. Then there are surgeons like Dr. Guts, about whom the most complimentary thing I've ever heard is, "Well, he's not quite Satan."

This is a man I once saw push a chart rack (remember those? Welded wire, meant to hold eight or so charts at once? Big, heavy three-inch plastic chart binders, full of paper, each weighing more than a couple of pounds?) over on to a unit secretary because he didn't like something that had just happened. Nothing having to do with the secretary. If she hadn't jerked out of the way, I think the weight might've broken both her forearms.

And here he was, in my unit. I should mention that Dr. Guts has quite the reputation for patching up people whose lower intestines have sustained damage of one sort or another. He's particularly good at reattaching colons to anuses.

Like attracts like.

The first words out of his mouth when I walked into his room were "GODDAMMIT! Why is this goddamned hospital so fucking disorganized??" I greeted him, introduced myself, and prepared to do a neuro exam.

"I was examined" he sneered--and I'd never actually seen anybody sneer before; I thought it only happened in books-- "by a qualifiedphysician less than four hours ago. I do not wish to repeat the exam."

"Good" I said. "That's gonna save me a lot of time the next time I have to assess one of your patients."

He looked at me.

"Because an exam by a qualified physician means that exam will stay stable, right? Now, look right here at my nose."

He hated the food. He hated our MRI suites. He kept complaining that the hospital was disorganized--a hospital he helped found--and that everything in the world was wrong. He bitched about the doctors, the night nurses, the phlebotomists from the lab.

Finally, midway through his second (and last) day on the unit, I said, "Is it possible for you to be any less of an asshole? Just for a minute?"

His wife, sitting on the couch with a book, said, "She has a point, dear."

A week later he was back on the wrong side of the bedrail, this time for a cardiac problem. Thankfully, not in my unit.

Tuesday, June 25, 2013

If you've been reading this blog for a while, you'll know that I've become addicted to renovation/decorating/house blogs.

It's a shameful thing.

It's a shameful thing because, to be honest, my addiction (which started when I bought this house, seven or so years ago) has resulted in nothing except my painting every wall in the house white. Well, and putting up those two-inch-wide, faux-wood blinds that JCPenney sells because I was sick of uncleanable Roman shades. Did that today. Lost some patience, some years of my life, and not a little bit of blood.

Somehow, despite being glued to Anna's and Daniel and Max's escapades, and reading Chezerbey with the sort of dedication I usually reserve for science fiction, I have missed all the finer points of design.

Dudes, I Used Pelican Tile In The Bathroom. In my defense, subway tile was still too expensive for my budget at the time, and I was under a huge time constraint, as a house functions best with a working bathroom. Still, I look at those squares of tile and kick myself every time I pee.

And, worst of all, I'm ashamed. My bedroom's been described as "stark"--as in, all-white, no frills, no tchotchkes sitting on things, and very few things for tchotchkes to sit on. The living room is mostly neat, with several bookshelves, but I spend most of my time keeping the dog-hair and cat-hair under control, not working out vignettes with the Thai dragon Dad got me years ago.

I'm a good cook. I'm fantastic at makeup. I can dress myself with only a minor amount of trouble. I can refill the windshield-washer-thingy in my car with no problem. I make gorgeous compost. I can handle power tools without losing digits, and my solder doesn't drip. I'm not the worst nurse you ever worked with. But I cannot for the life of me decorate.

I was excited when The Boyfiend told me he was bringing his Schlitz chandelier. (Which has since been lost, but I'll go into that tragedy later if ever.)

Tomorrow I'm going to IKEA. I'm going to buy curtains, following Dana's advice and getting the longer ones, and I'm going to put them up. I'm going to put them up, moreover, on the nifty bendy curtain rods I got a million years ago from West Elm. It's going to be fabulous.

Aaaaand they will make the rest of the bedroom look skanky and as if it needs to be repainted, which it does, but dammit, who has time for that when there are tomatoes to grow?

Wednesday, June 19, 2013

Not only do I have a new boss, I have a *fantastic* new boss. The honeymoon period is long over; I've worked with this person in a boss-capacity for going on two years now.

This boss, unlike the last boss, does not say things like "All vasoactive drugs are the same" and "I don't see why you're worried about your skills; you're a critical-care-trained nurse, right?" and "*I* had to work a whole twelve hours twice this week, so why can't *you* come in for a couple of extra shifts?"

All of which are verbatim from Old Boss's mouth.

New Boss says things like, "I'm expected at neuro rounds in ten minutes" (OB never managed to make a single round) and "No matter what happens, your unit will be taken care of" and "I don't know much about the brain, so I'm taking three classes in the next month to get up to speed."

NB also says things like, "It sounds to me like you guys aren't getting what you need in terms of support. What are your top three priorities, and how can I make those things happen?"

Also taken verbatim from New Boss's mouth.

I can't go in to too much detail right now, because every time I think about how my charts are being audited by somebody who actually cares, or my unit is being staffed by somebody who has actually worked as a nurse in a critical-care unit for more than nine months and who, moreoever, still does work in a critical-care unit to keep their skills fresh, I get all giddy and I can't type.

Everybody is happy about this: from speech pathology to physical therapy to the housekeeping staff, everybody's happy.

ANNOUNCEMENT NUMBER TWO: I have a new dog.

His name is Mongo, after the "Blazing Saddles" character.

Mongo likes snuggles, and kitties (and the cats love him), and playing catch, and carrying his stuffed toys around, and climbing up on top of me when there's a thunderstorm, and going for car rides, and generally being a capital-D Dog.

He's a golden retriever with separation anxiety. If he can't see me, but he knows I'm around, he flips out. I've asked the neighbors, and he hasn't been an asshole when I leave for work, so, good. We had a thunderstorm the other day when I wasn't here, and Mongo went calmly into his doghouse (evidence: he wasn't wet when I got home) and hung out.

His old human had to move and couldn't keep him. He's a year old. I never thought I'd have anything other than a shepherd or LSG or northern breed, but that was before I met Mongo-Man. He's the sweetest, lovingest dog I've ever met, even if he does bark when I mow the lawn. It took the cats about twenty-four hours to warm up to him; after that, I found them all three playing on the rug in the living room. Mongo was on his back with Flashes on his chest, biting his neck, and Notamus was playing with Mongo's tail.

Mongo is behind my chair right now, snoring.

And yes, he came with the name. It is appropriate.

No pictures yet because I can't get him to slow down long enough to take a snapshot.

ANNOUNCEMENT NUMBER THREE: Consolidated Research & Healthcare Corp, holding company of Sunnydale General, has done the dumbest thing EVER.

For years now, we've had color-coded scrubs according to discipline. The head of CRHC decided to drag us boldly into the 1970's, and has mandated that we all--from nursing to PT to housekeeping--will wear dark blue scrubs, the sort of blue you see in the cheaper catalog pages. Not only that, but they'll be embroidered (and thus un-returnable, in case they don't fit) and available only from one company.

I got mine today. They're cheap as fuck. As dark as they are, you wouldn't expect that a nude bra would show through them, but boy-hidey if it doesn't. They're available in two fabrics: Horrible Polyester and Slightly Less-Horrible But More Transparent Cotton-Poly. Other people, who got theirs earlier, have reported such things as the back seams on the pants ripping as they were put on or the shoulder seams ripping under the slightest stress. I can see why.

My only question is who's making money off this. Somebody somewhere has to be getting a cut of Sunnydale's employees' business.

Never mind that our patients, let alone our staff, had come to rely on color-coding to tell who was who. It's a nice thing, to be able to look up in the middle of a code and see maroon scrubs and know that RT has arrived. Those days are gone; now we'll have six-by-three inch plastic hangtags behind our IDs that state our discipline.

Of course, a fair number of my patients can no longer read, and depended on scrub color to tell what was going on.

I'd happily eat the cost of these scrubs if The Powers That Be came back and said, "Wait, never mind, bad idea," but I don't think that's gonna happen.

Tuesday, May 21, 2013

It's that time of year again, Minions. Those of you in Tornado Alley know what I'm talking about firsthand. Those of you not in the Alley know what I'm talking about thanks to the coverage of what happened in Granbury and Moore.

The Disaster Closet at Chez Jo is up and running once again. Hooray.

What, you might ask, is a Disaster Closet? Is it a closet where you keep your Bai Ling costumes? Your emerald-green eyeshadow? The mutant cakes that failed to rise?

Nope. It's where the cats and I go (and eventually The Boyfiend and The Dog, if ever the latter shows up) when the sky turns the same color as that eyeshadow and the sirens blow.

It's not common around here to have tornadoes, but tornadoes are not the problem ninety percent of the time. I once heard a storm-spotter describe a tornado as a sneeze in the middle of a really bad thunderstorm, and that's true. The majority of the time, damage in storm-hit areas comes from straight-line winds, hail, and--the big danger--flying debris.

That's why they say to get into an interior closet or bathroom with no windows. Trees falling, debris flying around--those are much more likely to injure or kill you than a direct hit from one of Mother Nature's sneezes.

Besides, if you take a direct hit from a twister, even a small one, there's not a lot your house will do to protect you.

(A quick aside, as people are surely thinking this: "Why a closet? Why not a basement or storm cellar?" In this part of the country, Austin north to OKC, it's difficult if not impossible to dig basements. We have three types of impediment: heavy clay soil, a layer of quartz or limestone between two and ten feet thick, and high water tables. Safe rooms are common in larger buildings, but it's damned near impossible to excavate deep enough even for a small storm shelter, let alone a basement. It's perverse to think that we settled the most dangerous part of Tornado Alley without figuring that out, but there you are.)

Anyway, and this is not bad advice for anybody anywhere anytime, it's a good idea to have a central location for Stuff You Might Need Later. Here's what I put in mine (all of this fits on a shelf above my head):

1. Weather radio with flashlight and cellphone charger. It's solar- or crank-powered and gets good reception even in the D.C.

2. A couple of big bottles of water. If the forecast looks particularly bad, I might stick a six-pack in there, too. (Only sort of kidding.)

3. First aid kit with pressure dressings and so on.

4. Insurance paperwork for me, the house, and the car.

5. Extra medications, extra contact lenses, extra pair of glasses.

6. A prybar. No, really. It's great to have a shelter from bad weather, but on the offchance that my roof caves in or blows away, I want to be able to get *out* as well.

7. The cats' carrier. They both go into one.

Everything except the carrier can either go on the shelf or, more likely, be slung in a cross-body bag and put on my person. So far, I haven't had to use the Disaster Closet in its fullest capability, but there's little sense in being unprepared.

Which reminds me of a funny story: a couple of years ago, we were having some pretty intense weather. Hail was hitting the sides of the house rather than the roof, the winds were so strong. Max and the boys and I were riding it out in the living room, waiting to see if the weather guys blew the sirens. When the sirens went off, Max fixed me with the stinkeye, then went to the closet, pried open the door with his claws, and went in. I followed him.

Thursday, May 16, 2013

Y'all have heard she had her boobs removed because she carries a mutant BRCA gene, right? And that she's gonna have her ovaries taken out pretty soon, too, right?

I cannot *believe* what folk been sayin' about that. First of all, it's nobody's place to have an opinion on what she does with her own body, even if she puts it out there in an op-ed in the New York Times. Second of all, if you have the kind of opinion that says, "She should've considered what that would do to her fans" or "She should've tried yoga and broccoli first," I will take you down.

Thursday, May 02, 2013

Let's review the bidding: Yesterday, the high was 85*F. That's somewhere north of 29 degrees for you guys who are using a sane and sensible temperature scale.

Last night, the low was 50*F. Today, the *high* was 47*F.

Tonight, it's supposed to get down close to freezing. I hope the tomato plants and basil live.

In short, go home, Texas weather. You're drunk.

I refuse to talk about nursing right now, because Manglement has indeed sucked all the joy out of my job recently. Instead of being sad that a friend of mine is leaving for a new job, I'm burning with envy.

So instead, let's talk about food. I have a craving right now for, not necessarily in order, osso buco, marrow on toast with capers and parsley, home-made donuts, and eggplant parmesan. All of those are wonderful, fun things to cook, and all of them will be totally untenable by Monday, my next day off, when the high is supposed to be in the 80's.

As much as people bitch about the foreignization of 'Murka, there is one benefit (well, more than one, but I'm concentrating on food right now): the amazing selection of offal available at my schwanky-danky, formerly snow-white grocery store.

I can get marrow bones so cheap it'd make you cry. Neck bones are even cheaper--hell, sometimes they *give them away*, which is just what you want for a lovely stew. The veal shanks that go into osso buco are not eighteen dollars a pound; they're practically free--if I ask for them at the butcher counter, I can get lovely meaty shanks for the price of ground beef.

And weird fish? We got weird fish, for pennies the pound. We haven't got that one with the human-looking teeth, at least not whole, but you want a monkfish tail? Eighty-nine fucking cents a pound, my friend. Yeah, you have to take that bad boy home and skin it yourself, but honestly? Not That Hard.

Also nopales, or cactus paddles: de-thorned and fresh, or pickled, or whatever. Dried squid in the bulk bins (particularly good deep-fried and served with scrambled eggs and sauteed eggplant OMG). Weird greens that I *think* might be amaranth, or some version of kale I haven't yet tried. Fruit that resembles pinecones. Fruit that looks like stars. DURIAN, FROZEN IN SLICES OR WHOLE IN A MESH BAG. And jackfruit.

If you haven't yet tried jackfruit, make friends with somebody from a culture that eats it regularly. The damn things get up to forty pounds, so it's not like there won't be enough to go around. Try it. Learn to tell a ripe one from one that's just soft.

And no, I haven't tried the durian yet. I can say that yes, it is the worst-smelling thing I've ever laid nostrils to, aside from a corpse plant in full bloom, and I totally understand why it's illegal in some places to take one on the bus or keep one in your hotel room. The smell is penetrating. You're afraid you'll never get it out of your nostrils. The inside, though, is supposed to be heaven.

Maybe I'll try a bit of frozen durian. A whole durian is large and intimidating, in addition to being smelly--I'm not sure I could get one home and cut it up without ruining it. You know those little spiny balls that sweetgum trees drop? Make that about eight pounds and you're looking at a durian fruit.

Anyway, food: Lots of it, most of it I've never tasted before, some of it (like fresh peas and beans and okra) is growing in the back yard as we speak. Most of it that I'm craving is winter food. It'll be warm again before I get a chance to eat anything more than cafeteria catfish (which, strangely, Sunnydale does beautifully and only on Fridays). I'll have to make do with fresh artichokes and asparagus and strawberries with almonds on a bed of butter lettuce.

Monday, April 22, 2013

So, when I visited the lovely Nikki and her cronies up in Seattle (heeeeeyyyy!), I came down with a Horrible East-Coast Plague brought by the lovely Lara. Lara is Gwyneth Paltrow; don't let anybody tell you different. Some say the world will end in fire, some say in ice; *I* say it will end with an innocent-sounding sneeze from Pittsburgh.

Three days ago, I came down with Plague Two-Point-Ought.

The doc could do nothing for me, since I declined her kind offer of multiple opiates for cough suppression. Even as lovely as that stuff can be, I'd rather cough until my toenails come loose than itch and be constipated and paranoid for days on end. Delsym, combined with Tiger Balm, Benadryl, and bourbon, does just as well.

She did, however, tell me that I can probably expect this to happen more often in the future. Not that she has a whole lot of patients with their palates missing, but, as she pointed out, it's only natural that the deficiencies in my muscosa would lead to greater susceptibility to virii.

I wash my hands. I alcohol-foam them. I keep them away from my face. I take prenatal vitamins, for God's sake, and zinc, and Vitamin D. I clean my prosthetic until it shines like unto the sun at noonday on the new-fallen snow. I stay away from sick people (yes, yes, I know, but stroke does not equal sick), I eat well, I exercise moderately at the frequency recommended by experts.

I fucking FLOSS.

And I got two colds in six weeks, both of which have left me sounding like I ate a bagpiper and producing snot the likes of which I won't describe.

Bourbon. Focus on that, chum. Bourbon, and Benadryl, and sit sleeping up so you don't cough.

Wednesday, April 17, 2013

Thursday, April 11, 2013

The good news is that we're very busy at Sunnydale (Healthcare for the Hellmouth). The bad news is that we're so short-staffed in every department except the one that does, like, colonoscopies and stuff that I've had five-patient days lately. As in, start with two, discharge those, get three.

The good news is that The Boy is moving down here in a couple of weeks, and that he has a fabulous new job that will keep me in beer to the point that I'll need to have my own floating scooter to get around the house. The bad news is that he's got shingles.

Yes, shingles. I diagnosed them over the phone after thinking to myself, "Gee, poison ivy doesn't usually occur along dermatomes along with a scratchy throat and a headache." He later went to an actual medical professional and confirmed it, and got all the meds he needs to fight off the outbreak.

Which is good, because the bad news is that I've never had chicken pox, and my titers have been falling the last few years. Herpatic encephalopathy is all fun and games until somebody goes blind or dies, and I, personally, have no intention of spending my remaining years drooling onto my own shirt while sitting strapped into a high-backed chair.

...Even though that sounds a lot like work.

Good news: I have, thanks to The Boy, newly weeded and replanted front beds. Bad news: we lost two tomato plants to unknown causes. Good news: there's a cardinal nesting in my rose bush, and she's laid three eggs. Bad news: I now have to find out what cardinals eat.

Good news: Changes are afoot at Sunnydale!

Bad news: They involve uniforms, not staffing. Manglement--and by this I mean the Tippy-Top people, who haven't, as far as I can tell, set foot in either Sunnydale or Holy Kamole in ten years--have decided that we all need to wear the exact same thing. From housekeeping to nursing to radiology, we'll all be wearing the same. damn. thing. Clinics to hospitals, top to bottom.

Good news: The uniforms are cheap. Bad news: They're in extremely limited sizes and are 100% polyester.

But, you know, what do you expect? When you're faced with a shortfall in staffing that's brought about by crappy working conditions and low pay, why *not* require everybody to buy new uniforms from the one place that you've declared will sell them? Bravo, Manglement, for addressing the troubles in our facilities in a constructive and thoughtful way!

Good news: I planted beans and peas and melons and carrots and radishes and okra this past week. Bad news: I watched a blue jay, that bastard, pull up each and every okra plant one by one and fling the sprouts around. The next batch I put in will be coated with cayenne pepper and bobcat pee. And will be hiding special Bastard Blue Jay Killing Machines.

Unmitigated good newses: The Boys went to the vet today and got a collectively clean bill of health. The exact words the vet used were "perfect," "beautiful," and "sweet." They're now sleeping off both the trauma of being cooed over and petted by six attractive young women, and vaccines. Flashes huddled in the exam room sink while Notamus tried to stand on his head in the corner of the room, but they both got over their jitters pretty quickly.

And now I am going to go Google cardinals' diets and head to bed. That's very good news indeed.

Monday, March 18, 2013

For some reason which I have been, as yet, unable to discern, those members of the public who are most inclined to attempt malarkey at the hospital choose neurological afflictions as their mode de malarkification.

I am SO TIRED of people who insist--insist!--that there is indeed a brain tumor, right here (points to right temporal lobe), despite the evidence of repeated MRIs to the contrary. I am equally as tired of people who have trouble remembering on which side they ought to be weak. And I've had it up to my moustache with folk who think that squinting is a facial droop.

So, in the interest of having something actually fascinating to deal with, I've come up with a list of things that malingerers shouldn't try, because we've seen them all before.

Numero Uno: SQUINTING IS NOT FACIAL DROOP. Seriously. I have all these fun little tests that I can do to prove it to you, plus: I watch you when you think I'm not watching you. Oh, and I read the charting from your forty previous admissions, so I know what you're likely to try. How many times do I have to say this, anyway?

Number Two: If you're gonna have weakness, make sure it's not distractable.

Number Two, subsection A: If you're gonna fall over, do it on a hard surface once in a while. We have a name for what you're doing: it's astasia-abasia, and it means we know you're bullshitting.

Number Two, subsection B: The same goes for upper extremity weakness. If you pretend to pass out, seize, or otherwise suffer an alteration in your level of consciousness, you bet I'll hold your hand about a foot above your nose and then drop it. If it misses your nose, I know you're faking.

Number Three: Telling me that you're allergic to morphine and "all NSAIDS" will not get you the IV Dilaudid you want. I weep for you, the Walrus said, I deeply sympathize: Dilaudid is the best shit ever in the history of the universe, and I certainly understand why you want it. However, you won't get it. Nor will you get Phenergan IV, or any of the other cool drugs, like Stadol. Here; I'll help you fill out the AMA paperwork.

Numero Quatro: Threatening to sue me won't work. Don't try it. Besides being rude and laughable, it's out of character for your illness for you to be able to holler unslurred words at me.

Number Five: This might bust up the angel-at-the-bedside myth about nurses, but: We Judge By Appearances. If you have no teeth, a heavy backwoods accent, track marks on your neck, and smell like an ashtray, we're going to be very, very cautious about what you're reporting in terms of symptoms.

Number Five, Addendum One: Likewise, if we read in your chart that you're on your fourth revision of a gastric bypass, have recently gotten out of rehab for the third time, and are allergic to morphine and all NSAIDS (see above), we're gonna lock up the narcotics.

Number Five, Addendum Two: In the same vein (no pun intended), we automatically double or treble the amount of alcohol use you admit to. That's why you're getting Librium with your scrambled eggs.

Number Five, Addendum Three: Yes, I will search your bag, your bed, your closet, your pockets, and everyplace else you could hide a stash after your family visits. I know these rooms better than you do, so don't even try.

Thank you for your time. We at Consolidated Research and Healthcare, Inc. know that you have a choice in healthcare providers, and we thank you for choosing us. We hope, wherever your final destination may be, that you have a safe trip. We hope to see you again soon, perhaps even in a sober state.

Thursday, March 07, 2013

The Festival That Cannot Be Pronounced has begun--well, technically is beginning--in Bigton. Littleton, where I live, is not unscathed by this yearly influx of techies, hipsters, and people who haven't seen soap in entirely too long. The traffic is horrible, my favorite beer store is out of my favorite beer, and the highways are full of people who, as they approach both downton Bigton and Sunnydale General, aren't quite sure where they're going. Hilarity, if you mean hilarity-in-a-natural-disaster-sense, often ensues.

Let it be recorded here that we, the group of women who if combined into one body, might make a fully functioning human being, had a hell of a time. We saw celebrities. We took pictures. Nikki and Tashi cosplayed and looked kickass doing it. I stretched my skillset by painting a tattoo on Tashi and fixing her wig. Lara became the human landing pad for a tiny kitten named Magda, who learned to kitty-parkour while we were there. The amazing Coyote, most patient man in the Universe, kept us supplied with donuts, fried chicken, and emergency telephone numbers. We played with makeup. We swapped war stories. We talked, ninety-nine percent of the time, about things having nothing to do with cancer (mostly Magda, who is at the Excruciatingly Cute stage). Der Alter Jo joined us one day, and it was all good.

Except that Lara brought some amazing East Coast Death Rhinovirus with her, and by day four, we were all down for the count.

The fun started on Friday night, when Lara damn near passed out during a midnight bathroom break, and yelled for Nurse Jo. By Saturday night, Nikki was feeling peaked, and by Monday, I was fully in the grip of the plague and on a plane home (sorry, seatmates).

I don't know what they do differently in Pittsburgh, but their upper respiratory infections are like nothing on this earth. In terms of body aches, it was right up there with the flu; the only difference was more snot and a lower fever.

Today I rose from my bed, looked around blearily, and ate some soup. Tonight I'll go to bed early and sleep through the night with any luck. Tomorrow it's back to work for me.

Wednesday, February 20, 2013

Or, for that matter, to your family members when they're in the hospital.

(Inspired by this post at XOJane, and by my own experience over the weekend.)

I had a patient this past weekend who was, by any definition, a Big Girl. Several inches over six feet, broad and strong in proportion to her height, and well over 300 pounds. She'd had a crazy-ass, rare clot in a weird place that had landed her with us. She also had a relative who, while well-meaning, was a royal pain in the patookus in regards to her weight. The relative, incidentally, was also tall, but very, very slender. And had an obsession: her relative's--my patient's--weight.

So I'm in the room, talking to the patient about her Cray-Cray Clot, and the relative starts in about the patient's weight. "You need to tell her she's fat," the woman says, "and that she needs to lose weight."

This is true. She is fat. She's way the hell over what any rational person would consider a healthy weight.

Nonetheless, she had recently finished a half-marathon. She played tennis twice or three times a week, and led a water-aerobics class a couple times a week. Her mobility was not impaired. Her lipids and blood pressure were normal. Medically speaking, she had no problems at all save an extra hundred pounds.

So I turned to the patient. "Do you own a mirror?" I asked. "Yes" was the reply. "Do you know that you're fat?" I asked. "Yes, of course" said the patient. "Are you aware of research that finds that extra weight can lead to health problems?" "Yes."

"There. Done" I told her relative.

Which brings me to my first rule of dealing with fat people: Do not treat them as though they don't know they're fat.

As a fat person myself, I am constantly reminded that I'm fat. I can't buy clothes from straight-size stores, I am always the largest person in any group picture, and there are some things I find uncomfortable to do because of my weight, like going down stairs. (Going up stairs is easier on the knees, and my aerobic capacity means I'm often outdistancing my skinny colleagues. Still. . .)

If you're fat, you know it. Please give us fat folk the benefit of the assumption that we have brains.

Then the relative asked me straight out if the Cray-Cray Clot was due to the patient's weight.

It wasn't, and I told her so. It was due to the fact that the patient has a rare clotting disorder that hardly ever shows up in women.

In asking that question, Relative had fallen into the same trap that all the doctors who'd seen Patient had fallen into for months. Despite an unyielding headache and neurological changes, the docs who'd seen her hadn't looked at her brain; instead, they'd blamed her weight for her symptoms. Doing so had led to a three-month delay in diagnosis, incalculable damage to her brain and spine, and a lot of pain.

This is Rule Two: Not everything that is wrong is due to excess weight. Do not be blind to the fact that there might actually be a problem that can't be expressed in BMI.
Back in the day, doctors blamed wandering uteri for everydamnthing that went wrong with their female patients. This is exactly the same thing: blaming the most obvious factor for all the trouble ever. Fat equals wandering uterus in today's medicine. Do not blame fat: look for an underlying cause. Examine your patient's general health and activity level. Dig deeper.

Eventually, Family Member took me aside and asked me to have a serious talk with the patient about her weight. If she would just eat less, Family Member said, all her problems would be solved.

I leave it as an exercise for the reader to determine whether or not this is true. (Hint: it's not.)

By the time you get to be fifty, or a hundred, or five hundred pounds overweight, there are other things going on besides overeating. It's not a failure of willpower or a lack of knowledge and understanding. Thirty years ago, we had that attitude about drug abuse: if the person would Just Say No, things would be unicorns and rainbows and the world a better place.

Really severe obesity is a product of a multitude of factors, most of which have nothing to do with food per se. Therefore, my addressing one facet of the problem by saying "Hey, I just met you, and this is crazy, but you eat like a fucking pig, so cut back, maybe" is not going to help. At best, it's telling somebody something they already know. At worst, and most commonly, it demonstrates a lack of respect for whatever deeper issues that person's dealing or not-dealing with.

Morbid obesity is like heroin addiction: it starts from a place deep in somebody's psyche and has to be addressed holistically.

So here's Rule Three: Fat is not about food. Fat is about something else. Don't insult your patient, or your loved one, by assuming that it's just about the calories.
"If you want to help," I told Family Member, "you could reassure Patient that you love her no matter what her size is, and that you'll be there for her if she needs you. Right now, you're telling her that your love and acceptance is conditional on her being thinner. That's a losing game."

Finally, and without illustrative examples, here is Rule Four:

Fat is a descriptor, just as "strong" or "red-haired" or "really good at eye makeup" is. "Fat" does not mean "lazy" or "slovenly" or "smelly" or "bad."

Fat is just another adjective. Avoid making value judgements about somebody just because they're bigger than you, or--equally important--hating yourself because you're not at an ideal weight.

If I had my way, everybody would feel comfortable being who they are. Nobody would feel bad about how they look or however it is that they don't conform to whichever ideal is in fashion. People would eat greens and trot around enthusiastically and take their baby aspirin daily and be cheerful about their futures.

That's not likely to happen soon, so in the meantime I'll deal with the fracas surrounding fatness.

Saturday, February 09, 2013

Doctor Annoyance is going away. I don't care where or when, though I know when the when will be, and believe me, it's not soon enough: he's going away.

Doctor A has been a thorn in my side now for longer than I care to consider. He's one of those doctors--you know, the ones who can't find a phone number on their own, or who ask you stupid, unimportant questions in the middle of a crisis, or who think they're being cute when what they're really being is totally off the chain and for God's sake will you just TAKE IT DOWN A NOTCH ohmygawd how many times do I have to tell you

. . . .Anyhow, he's going.

And, with him, goes another colleague--one so toxic (as the kids say) that I didn't know how much my work life was being affected.

I wrote a piece t'other day for Scrubs about toxic workplaces and nasty, poisonous coworkers. I hadn't connected that bit of writing with anything that was going on in my own precious unit until now. Turns out I was speaking more truth than I had ever imagined.

For the last two years, my daily life's been made more unpleasant by somebody who can't see the good in anything. Swear to Frog, if this person won the lottery, patented a device to reverse global warming and remove pollution from the air, and cured cancer, all in one afternoon, there would still be bitching happening. Some people are never happy, and this is one of those folks.

And they're leaving. Cue my happy-dance. They're leaving, and they're taking Doctor Annoying with 'em, and for the next week, I am going to be blissed out and just smiling like a fool.

In other Hooray news, I have a confession to make: a sexist, horrible, awful confession:

There is some serious eye-candy happening in my unit these days.

We got a new crop of residents in as part of the half-year switcheroo, and although I know most of them, there are a few lovely strangers to gaze upon. (Yes, yes, I know. They're all young enough to be my children and they're professionals and so on and so forth, but dayum.) HR has also given the go-ahead to hiring what seems to be America's/Australia's/Canada's/Backobeyondistan's Top Model candidates for the night shifts, and all of 'em are orienting, in succession, to the NCCU.

Aside from a I-will-always-say-something-stupid moment when I tried to guess where one of the newbies was from (I guessed Ireland; turns out the correct answer was New Zealand), things have been going swimmingly. Not only are these guys--because they're all male, and what's up with that?--easy on the eyes, they all came in knowing what three-percent saline is for and how to do an NIH stroke scale exam. They're all experienced. They're all certified. All I've had to do the last three weeks is show 'em where the coffee machine is, tell 'em how to access the computers, and turn 'em loose. This is in contrast with what I've been doing lately, which involves equal parts babysitting, computer training, and hand-holding.

Is there an asteroid due to hit soon?

Because, if there is, I want to open my mouth as wide as possible and show it my tonsils before I get blown to cinders. And therein lies the last Hooray bit of news: my two-and-some year's checkup was clean as a whistle.

Dr. Crane said that thing that used to be my mouth looked "beautiful," and as I was getting all puffed up about it, added, "The Prosthetic Elf always does such good work." Still, it's nice to know that I am still officially without evidence of disease. The next exam's in August, and I'll have a good old time freaking out about that, as I'm supposed to get an MRI a week prior.

I'm tempted to deck out an IV pole with streamers and fake flowers and ride it around the unit, waving like Queen Bess at everyone.

Monday, February 04, 2013

The screaming was so loud that it brought me out of the room nearest the nurses' station with a "What the HELL?"

It was a toddler. I don't know jack about babies, except that they're generally wet at one end and loud at the other. This one was both. This one was open-mouthed, red-faced, screaming its little head off, in the arms of my flummoxed-looking coworker. He (the toddler, not my coworker) seemed to be about walking age, maybe a little younger; a cute kid, aside from that awful noise.

So we took him into one of the larger storage rooms and proceeded to play games like "What's on my head?" and "Can we shut you up with cookies?" Coworker dealt with the diaper while I went back to being a nurse.

After thirty minutes of nonstop hollering (poor kid was really upset), the child's father came back to get him. The child's father is an attending physician--not on the neurocritical care service, thank God--and had come in for morning rounds. His wife was out of town. Apparently babysitters do not exist.

Except in the neurocritical care unit! This is the fourth time in as many weeks that a male, attending physician has brought one or more children with him and left said child(ren) in our care for anything up to an hour. One dude dumped his kids off in the nurses' station break room around lunchtime with hasty instructions to "feed them something and keep them entertained."

I can't even. There are so many things to unpack here that have to take them in list form:

3. Nurses are not babysitters. We have things to do, even on weekends.

4. Bitches do not, universally, love babies.

5. Can you imagine what would happen if a resident brought in his or her kids?

6. Oh, God, if a female resident or attending brought in her kids, she'd never live it down.

7. Kids are noisy. It's part of being a kid. Units where stimulation is kept to a minimum is not a place where kids can or should be noisy.

8. You are old and experienced enough to know better.

9. WHAT THE HELL ARE YOU DOING, BRINGING YOUR KID TO ROUNDS? It's not like rounds are a sudden, unforseen emergency. They happen every day at a given time. You have time to prepare, to have a plan A and a plan B and even a plan C, should that be necessary.

Thankfully, the charge nurse of the other CCU that shares our floor said something to the doc. Had I opened my mouth, I would've blasted him to a cinder and salted the charcoal. Still, we wrote him up--the only concrete action we can take when a physician does something so inappropriate.

If this were just one physician, or just one service, it'd be easier to handle. Instead, it's different guys at different times, which means it's a part of the hospital culture. That'll be fun to address.

So, guys, if you're thinking that it's a slow Saturday at Sunnydale General, and that nobody'll mind watching your child for however long you need 'em to, just don't.

Tuesday, January 15, 2013

It was a gun specifically designed to kill people with as much efficiency and as little subtlety as possible: a twenty-gauge shotgun with a barrel so short it skirted the legal limits, bought without a background check on the grey market, loaded with shells full of buckshot. I didn't buy a twelve-gauge because I'm a lady, and larger shotguns kick like hell.

If I had fired it, it would've put a huge, bloody hole in my target, the wall behind and on either side of him, and anything else within about twenty feet.

I bought it about six weeks before I had surgery, from a guy at work. I paid in cash and felt better, because I knew that in my weakened, post-surgical state, as a woman living alone, I would not be able to fight off any intruder who had gotten past shatterproof windows, steel doors, and Max.

(I still miss Max terribly. I never felt safer than when he was lying in the exact spot where he could see both the front and back doors at the same time. He was a Good Boy.)

Still: I was looking at several weeks, if not several months, of recovery from a nasty surgery. I felt small and alone and afraid, and so I bought a vaguely illegal gun that required no skill to shoot. I'm such a newbie that a friend of mine cleaned and loaded it for me and showed me how the safety worked.

Once I got better, I sold it back to the guy who'd sold it to me, for the same price, as it had not been fired. Now I have a can of wasp spray, which is both blinding and neurotoxic. In the words of my hippie massage therapist, it'll fuck a body up.

Beloved Boy owns a number of guns. He hunts, so he has guns, QED. He has one self-defense weapon, a semi-automatic Czechoslovakian pistol with a reminder to "Owner's Manual: Read Before Using" etched on the barrel. Its clip holds 18 rounds of ammunition which, if it hit you in the right spot, would be instantly lethal. If it were to hit you in the not-right spot, it'd be very messy and damaging. If you hold the trigger down, it shoots, then pauses, then shoots, which (as I understand) is what makes it semi-automatic. It's a gorgeous piece of technology and not one I'd ever want to use.

That said: I support the right of the individual to bear arms. I support the idea and practice of a well-armed local defense force, as exemplified by the National Guard. The Second Amendment and I are buddies from way back.

I do not like semi-automatic weapons with large-capacity magazines. Nobody needs them, and nobody should have them, including Beloved Boy.

Because, frankly, all it takes to kill a human is a single-shot, pump-action shotgun with the correct sort of ammo. Load that sumbitch with the right stuff, and you're pretty much done with the discussion. More than that is way too much icing on the cake.

Guns aren't meant to paint pretty watercolors. You wouldn't use one to wash your car or change a baby's diaper. Guns are meant to kill, whether it's ducks or deer (oh God oh God I know I'll have to roast a duck at some point please don't make me clean it ew) or people. There has to be a limit, a boundary, to the amount of killing any one person can do at any one time.

So yeah, I'm all for renewing the ban on assault weapons. I want limits on high-capacity magazines, because for God's sake, who's going to hunt a fucking deer with a 36-shot clip? If the Tyrants of the Twenty-First Century come after us, they'll be armed with nervines and poison gas and nonlethal weapons that'll make Star Wars look like a children's cartoon. No assault weapon is worth its weight if you're vomiting and having uncontrolled diarrhea from sub-sonic vibrations.

I wish, at the end of the day, that I'd trusted Max more, that I hadn't felt the need to spend money and brain-time on something lethal. I had shatterproof glass and fireproof and kickproof doors and a big, handsome boy with huge teeth; what more did I need? I bought a gun because I felt weak and small and afraid.

And I wonder how many other people feel weak and small and afraid in the face of what life sends them, and compensate by getting an AR-15.

Sunday, January 13, 2013

I got to thinking about this the other night, as I was rinsing out the enormous (well, not enormous, but it feels enormous) hole that goes directly from my mouth to my right sinus:

1. Sinuses catch a lot of stuff.

Seriously. The crap I wash out of my sinuses every couple of days would make a strong man shudder and a scientist's eyes gleam with excitement.

2. You don't know how lucky you are to have a palate until you don't.

You normal people have NO IDEA how much snot you produce. Trust me on this one.

3. I can't eat flour tortillas under any circumstances, and should probably stay away from baked potatoes, Tater Tots, macaroni and cheese, and muffins.

Some things stick to my obturator with the tenacity of an angry giant squid. Other things work their way into my turbinates, to be sneezed out a few days or a week later, causing me great alarm.

4. I am so fucking lucky not to have had to have radiation.

I had a patient today who had radiation to his face and neck and who felt pain while eating a can of peaches. Just chewing had caused a pathological fracture. The surgical response was to remove half of his lower jaw. My pal Mary is dealing with a less-horrible, but still awful, sequel to radiation. I was very, very lucky.

5. When you have something that's considered rare, information and statistics and so on change in a matter of months.

When I started the journey with CANSUH, the stats were that three of every four patients that got what I have, polymorphic low-grade adenocarcinoma, were female. Now it's four men in every five patients. Smoking and drinking seem to have little to no bearing on whether or not you get it. Endogenous or exogenous estrogen no longer matters. Spicy food isn't considered a problem, unless you get some of that Thai long pepper up over your obturator. See comment on point #2.

When I started this whole thing, the assumption was that a complete cure could be had with aggressive surgical resection. Now the understanding is that PLGA can come back seven, ten, even twenty years after resection, and even if radiation was used as an adjunct.

When I started treatment, PET scans were considered the standard for monitoring. Now, given the indolence of the tumor, doctors are questioning how effective technology is. Apparently, a tumor can get to be quite a respectable size before it shows up on scans. Now, hands-on scoping and poking is the latest thing.

Essentially, I got told during my last ENT visit with Dr. Crane that the best I could do was NED--No Evidence of Disease--forever.

Well, shit.

In a way, it sucks to go from "we have a complete cure" to "you have to be careful." In another, it's nice to know where I stand. I never really trusted that "complete cure" thing anyhow. When you've had a piece of your body removed with a bone saw, you tend to get a little spooky about confident predictions.

All of this sounds, in the balance, negative.

However: I'm sitting here, more than two years after my surgery, blogging. I just scratched my own back and felt how incredibly dense and thick my back muscles are. I'm strong, I'm fat (which, if you're in my shoes, is not necessarily a bad thing), I'm back to lifting weights three times a week and running nine-minute miles. I can do yoga without falling over much. The Boy can understand me when I talk without my obturator in, and says it's getting easier to do so with every passing month. (He takes me the way I am; I am so incredibly lucky for that.) I have all but one of my teeth; two if you count the one that was never going to erupt, since it was lying horizontally under my cheekbone.

I look normal. That is such a huge, huge thing. I sound normal. That's even bigger. Two years ago, I wouldn't have believed you if you'd told me that I would *feel* normal with an obturator in--do you remember the struggles I had? I do.

The cancer might come back, or I might get some other type. I'm half-expecting to have to say, "Mother-FUCKER. AGAIN???" when I get my mammogram this year.

The difference between now and two years ago is this: Not only do I know I can survive all the stuff that happened, I know I can do well through and after it.

I can do anything, now. Just about damn near with very few exceptions anything.

Saturday, January 05, 2013

One thing I can say for people in the sixteenth and seventeenth centuries: they had one hell of a collective sweet tooth. Make a pie of artichoke bottoms? Strew it with sugar before you serve it to table. Boil a calve's chaldron (which I just found out is entrails) and spice it with mace and nutmeg and cinnamon? Sprinkle a little sugar over that mofo before you serve it up in a pasty. Roast a rooster? Sugar. Making a nice (meaning exacting) recipe for biskit? Sugar. Sheep's feet? Sugar.

When a recipe starts with "Take a pound of sugar, seirced, and lay it onto four pounds of butter, add enough flower to make a past with rosewater and fresh Milk," you know you're really on to something.

My goal is to find recipes that don't involve too much sugar, like roasted capon with a cream/anchovy/egg yolk sauce, and try to make them. The trick is deciding when "enough" is really enough, as most of the recipes say to bake, boil, or chafe something until it is enough or is meet.

The best instructions I've found so far are for Makeing a Caudle After the French Manner, in which you are directed to Seethe as much Milk as is fit on the Coals of the Fyre, and when little Pimples appear, you are to Take It Off and Coole It by the Fyre until it is Hardened, which, ew.

In that vein, I offer two recipes, primarily for Friend Penny The Lotion Slut, but also for anybody who needs soup. Non-vegetarian alternatives for the first are given in parenthesis.

Auntie Jo's Pseudo-Mexican Veggie and Corn (and Chicken) Soup:

In preparation:

Pour one box of vegetable stock (chicken stock)--Kitchen Basics makes an excellent one--into a very large pot

Set to seethe over a low fyre.

Meanwhile, chop one small or one-half of a large Onyon
Two Peppers, either Poblano or Bell, (but not green bell, because they suck)

And wilt (fry over very low heat) them in a little vegetable oil

Open three cans of beans: one white, one red, one black. Dump them into a colander and run water over them until those weird starchy white bubbles no longer form. This process will take out the fartification chemicals.

(If you want to make this with chicken, now is the time to add your preferred cut of said bird to the stock. When it's simmered enough that there's not actual blood coming out of the meat, you can pull out the meat and shred it, then return it to the stock.)

Add the onion/pepper mix to the stock.

Add one can of petite diced tomatoes with juice.

Pour in enough water that you've got a kind of watery thing going on. You're going to cook this for a good while, so don't be afraid to add plenty of H2O. I usually add about four cups.

Now add your beans. If you have a bag of frozen corn in the freezer, the cheap sort that is sold for fifty cents a bag, add that too. A can of shoepeg or regular corn, well-drained and rinsed, will do as well.

If you're doing this right, you should have about a gallon of very watery soup: enough to make you wonder if this was a good idea. You're doing fine, don't worry. (How I wish this reassurance came in 16th century recipes!)

Now for two spices: cumin and chili powder. You are a fool if you use hot chili powder for the majority of this, since you want to dump in at least a quarter-cup of each. Seriously: you want this sonofabitch to be a dark red color with a hit of cumin to your nose. If you want the heat, you can add a couple tablespoons of hot chili powder about midway through, but don't use all hot; you'll be sad.

Allow to come to a boil to kill off bacteria. Then simmer for several hours, or until it looks like supper. (For reference, I usually have at least an inch of soup-ring around the edge of the pot before I serve it.)

This makes a lot of soup. I freeze about three quarts every time I make it. Serve with shredded cheese and tortilla chips, either on the side or crumbled in. Do not sprinkle with sugar before taking to the table.

Auntie Jo's Weird Pseudo-Tabbouli Thing Made With Kale
I'm actually very proud of this. It keeps forever and tastes better the second, third, and fourth day.

Get you one bunch of kale. Curly or not, doesn't matter. It's cheap, so maybe you should get two.

Get you a bunch of parsley. The flat-leaf Eyetalian kind is best, but you can skate by with that curly stuff.

Get the other half of that onion out of the fridge.

Buy a long English cucumber, one red or yellow bell pepper, and three good tomatoes, if any are to be found in the winter.

Be warned: this is a labor-intensive recipe.
Wash your kale in several changes of water. The easiest way to do this is to fill a really big container with cold water, plunge the vegetables in and swish them around, then yank them out. Empty the container and rinse and refill, then repeat. You can't be too careful with kale, as it tends to be sandy.

Do the same with the parsley.

Dry them both by shaking them out, then wrapping them in a dishtowel. Set that mess aside.

Set all of that aside. Now you're starting the really labor-intensive bit:

Stem the kale. This is most easily done by simply grabbing the leafy parts of the kale and ripping them off the stem. A little stem is okay, but not a lot, as kale stem is best digested if you have four stomachs.

Stem the parsley. You don't have to be as careful with this. As a matter of fact, I usually just cut off the top two-thirds of the bunch and save the rest for stock.

Chop the kale and the parsley together (you should have about equal amounts of each) very, very finely. No, finer. No, finer than *that*. You want the two to be indistinguishable on the cutting board. Seriously: chop it fine fine fine. Otherwise, the kale will be tough.

Mix the kale/parsley stuff with all your other veggies. Salt generously. Use some pepper. Squirt more lemon juice than you think is wise over it, then finish with a dollop of olive oil. Stir. Refrigerate. Eat entire bowlsful for lunch.

Sometimes I add quinoa to this to make it a main dish. Sometimes I just eat it straight out of the bowl, standing in front of the fridge, when I get home from work.

You could possibly use a food processor for the chopping, but only if you're better with a food processor than I am. I got kale and parsley pesto the first time I tried, and haven't gone back.

Do not Boyle with a Large Blade of Mace, or bruise with Sugar, or Bake in Coffin until Fit.